AVIVA AT FITZSIMONS

13525 E 23RD AVE, AURORA, CO 80045

Independent ratings: No payments from facilities
B

Meets federal staffing minimum — above average inspection record.

Quality Breakdown

RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
1.29 ✓ Meets federal minimum
Health Deficiencies
Violations found during federal inspections over the last 3 years.
8
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
Quality: ★★★★★ (5/5)
Staffing: ★★☆☆☆ (2/5)
NursingHomeGrade Score
77/100

Data last updated: April 12, 2026

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

Most recent inspection (October 8, 2024)

F Potential harm — widespread F0851 Status: Corrected

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Administration Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2024

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2024

E Potential harm — pattern F0730 Status: Corrected

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2024

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2024

D Potential harm — isolated F0813 Status: Corrected

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2024

D Potential harm — isolated F0759 Status: Corrected

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2024

G Actual harm — isolated F0689 Status: Outstanding

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Past Non-Compliance

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2024

Inspection cycle 2 (July 31, 2023)

F Potential harm — widespread F0908 Status: Corrected

Keep all essential equipment working safely.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected August 3, 2023

E Potential harm — pattern F0921 Status: Corrected

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected August 3, 2023

D Potential harm — isolated F0761 Status: Corrected

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 3, 2023

E Potential harm — pattern F0679 Status: Corrected

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 3, 2023

D Potential harm — isolated F0697 Status: Corrected

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 3, 2023

D Potential harm — isolated F0658 Status: Corrected

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

F Potential harm — widespread F0842 Status: Corrected

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 3, 2023

E Potential harm — pattern F0585 Status: Corrected

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 3, 2023

Inspection cycle 3 (April 6, 2023)

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2023

D Potential harm — isolated F0808 Status: Corrected

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 7, 2020

E Potential harm — pattern F0812 Status: Corrected

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

E Potential harm — pattern F0760 Status: Corrected

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 3, 2023

G Actual harm — isolated F0684 Status: Corrected

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 3, 2023

D Potential harm — isolated F0686 Status: Corrected

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2023

G Actual harm — isolated F0689 Status: Corrected

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2023

D Potential harm — isolated F0657 Status: Corrected

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 2, 2020

D Potential harm — isolated F0658 Status: Corrected

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 30, 2019

D Potential harm — isolated F0550 Status: Corrected

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2023

E Potential harm — pattern F0573 Status: Corrected

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected April 7, 2023

D Potential harm — isolated F0585 Status: Corrected

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 9, 2020

Quality Assurance & Integrity

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